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Could Sexting Help Your Relationship?

NPR Health Blog - Sat, 08/08/2015 - 8:03am

It's not just teens who engage in sexy texting. About 82 percent of adults recently surveyed say they've sexted, too.


Sexting is scandalous, dangerous and downright dirty behavior.

Or, at least, that seems to be its reputation, maybe because most studies of the behavior have focused on teens. Among young adults, exchanging explicit messages and photos by phone has been linked to higher rates of early sex, sexually transmitted diseases and drug and alcohol use.

But some psychologists think the negative connotations of sexy texting aren't entirely fair. The behavior may have benefits, too, they suggest, at least for consenting adults.

"If [sexting] was only a bad thing, people wouldn't do it as much as they do," says Emily Stasko, a doctoral student in clinical psychology at Drexel University.

To investigate the benefits and downside among adults, Stasko and some colleagues asked 870 people between the ages of 18 and 82 to fill out a survey about sexting. Participants answered questions like, "Have you ever sexted, and with whom?" and "Do you consent to sexting even if you don't want to?"

The researchers, who described their findings Saturday in Toronto at the annual meeting of the American Psychological Association, report that many of the adults — 82 percent — admitted to sexting within the last year.

The psychologists also found higher frequencies of sexting to be associated with greater levels of sexual and relationship satisfaction — when it's wanted.

"Context mattered and not all sexting is equal," Stasko says. "Unwanted sexting is bad for relationships, but when it's wanted, it's good."

What surprised her, she says, was that the frequency of the behavior, and reports of benefits, didn't differ by gender. Men and women reported similar levels of sexting, and the positive association was the same when it was desired.

Psychologist Susan Lipkins, who has studied sexting in the past, says she can see how the form of communication could be a good thing for relationships. But the experience of sexting, she says, is most likely different for men and women.

"Men are more visually oriented so they're probably more interested in getting sexually explicit pictures," Lipkins says. "Women respond, too, but we don't look at private parts in the same way men do. Women want to read words that are positively reinforcing the male's desire to be with her; words that make her feel sexually special and desired."

Still, Lipkins thinks this study doesn't prove sexting leads to a better sex life or happier relationships.

And Stasko agrees.

"We don't know if sexting promotes intimacy," Stasko says, "or if people who are in satisfied relationships feel more intimate and that leads to sexting."

But she says she's hopeful that if more studies show sexting promotes intimacy and satisfaction, it might be be used in couple's therapy as another form of enhancing communication.

What we can say, Stasko says, is "sexting can be good."

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Crime Interrupts A Baltimore Doctor's Reform Efforts

NPR Health Blog - Fri, 08/07/2015 - 3:25pm
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Workers for the Safe Streets violence interruption project including Gardnel Carter, center, talk with Baltimore residents in 2010.

Kenneth K. Lam/MCT via Getty Images

On a hot, sunny Monday in mid-July, Dr. Leana Wen stood on a sidewalk in West Baltimore flanked by city leaders: Mayor Stephanie Rawlings-Blake, interim police commissioner Kevin Davis, Rep. Elijah Cummings. Under a huge billboard with the web address, she proudly unveiled a 10-point plan for tackling the city's heroin epidemic.

Wen, the city's health commissioner, said she aims to create a 24/7 treatment center, an emergency room of sorts for substance abuse and mental health. She spoke of targeting those most in need, starting with those in jail.

What Wen did not know was that, across town in East Baltimore, police had hours earlier arrested two workers with Safe Streets, the health department's flagship anti-violence initiative.

The project, first launched by the health department in 2007, hires ex-offenders to go into the streets and mediate conflict before it erupts into violence. They're called violence interrupters. It's based on the Cure Violence model out of Chicago.

The workers have credibility in their communities because they are from those communities. Some have histories in the drug trade, and many of them have served time in prison.

What had happened was that in the wee hours of the morning, police responded to a call about an armed robbery. They chased the suspects to an address which turned out to be a Safe Streets neighborhood office. Inside, police found guns, drugs, and paraphernalia related to the manufacture and sale of drugs, including sifters, cutting agents and scales. Nine people were arrested, including Two Safe Streets employees who face gun and drug charges.

It wasn't the first time Safe Streets workers had gotten into trouble. And Wen says she knows there are risks in hiring ex-offenders.

"But everything has risks," she says "In my work as an ER doctor, there's no procedure that I can recommend, no medication I can recommend that doesn't come with a risk."

Research shows Safe Streets does deliver. Last year, the health department says the program mediated 880 conflicts in Baltimore. Until recently, a couple of the neighborhoods they operate in had gone a year without a fatal shooting.

At the time of the arrests, Wen and the health department were preparing to announce the opening of a fifth neighborhood site for Safe Streets. There was talk of it opening in Sandtown-Winchester, Freddie Gray's neighborhood.

Instead, Wen appeared at a press conference at police headquarters, this time flanked by the police commissioner and federal agents. She reported that the raided Safe Streets site had been suspended and that two employees had been fired. She strongly defended Safe Streets as a program, and spoke of standing united with the police and partners in reducing violence in Baltimore.

Her words had been chosen carefully. But there were problems.

She soon learned from her deputy Olivia Farrow that the Safe Streets staff was not happy.

Part of the problem was the image.

"People were upset to see me standing with the police in the first place," Wen told us. "Because the entire point of Safe Streets is that they're separate from the police, and in the mediation for conflicts, there has to be total trust. And we had potentially interfered with that relationship."

So she sets about trying to fix things. She calls a meeting with the Safe Streets site directors. She brings in Brent Decker from Chicago's Cure Violence, who trained many of the Baltimore staff, as well as violence expert Daniel Webster from Johns Hopkins University.

They talk about what could be done differently to keep staff from falling back into their old patterns and getting involved with drugs and crime. They discuss providing more counseling for the staff, who themselves have been perpetrators and victims of violence.

Wen then turns the conversation to a topic she'd heard about in one of her early visits to the program.

"Initially when I was meeting with Safe Streets, I said, 'What is the one type of support we can help you with?' And I thought they were going to say trauma debriefing, mental health support. And they said child support."

That puzzles her. She wonders why she would be helping with child support in the first place, and also just how that would be done.

Dante Barksdale, Safe Streets' outreach coordinator, explains that most of the guys coming to work for the program are over 30, which means they're likely to have children. Many owe upwards of $50,000 in child support. The Safe Streets jobs pay about $28,000 a year.

A couple months after they start working, the state starts deducting child support from their paychecks, leaving them with very little. Most of these men have never held jobs before and don't have the skills to find other work. All of these factors make for a very stressful transition to legal employment.

"We see that a lot," Barksdale says. "That translates through all the sites."

Dedra Layne, who oversees Safe Streets at the Health Department, proposes talking with the bureau of child support enforcement.

"If they don't know that we're faced with this issue, they can't do anything," Layne says. "We should at least be having the conversation about are there any options to consider. Are there any things that we can put in place that would support the staff as they move through their first employment opportunities and still have families to manage."

What started as a conversation about preventing violence has now wandered into the realm of child support law, further and further away from what many might think of as public health. But Dr. Wen pushes on.

Leana Wen talks with Safe Streets outreach workers Dante Barksdale and Gardnel Carter in Druid Hill Park in Baltimore.

Meredith Rizzo/NPR

"Have there been, around the country, efforts to do different types of salary arrangements to bypass the child support problem?" she asks. "An example might be instead of paying child support directly, have there been experiments to see what happens if we pay for housing?"

Heads nod around the table. They don't know if it will work, but the sense is it's worth looking into.

No one here would argue that child support isn't important. In a different story, we might be using the term "deadbeat dads" to describe this problem. But what do you do when your deadbeat dad is someone who voluntarily puts himself in dangerous situations for the good of the community, wedging himself between people who literally want to kill each other? What do you do when your deadbeat dad represents your hope for the city, if only he can stay on track?

These are the questions that Leana Wen is wrestling with. And like so many other questions in Baltimore — there are no easy answers.

NPR and All Things Considered will continue reporting from Baltimore in the coming months, checking in with Leana Wen and her team periodically. Stay tuned for future stories.

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Eye Shapes Of The Animal World Hint At Differences In Our Lifestyles

NPR Health Blog - Fri, 08/07/2015 - 2:11pm
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Can you guess which eyes belong to what animal? Top row, from left: cuttlefish, lion, goat. Bottom row, from left: domestic cat, horse, gecko.

Top row: iStockphoto; bottom row: Flickr

Take a close look at a house cat's eyes and you'll see pupils that look like vertical slits. But a tiger has round pupils — like humans do. And the eyes of other animals, like goats and horses, have slits that are horizontal.

Scientists have now done the first comprehensive study of these three kinds of pupils. The shape of the animal's pupil, it turns out, is closely related to the animal's size and whether it's a predator or prey.

The pupil is the hole that lets light in, and it comes in lots of different shapes. "There are some weird ones out there," says Martin Banks, a vision scientist at the University of California, Berkeley.

Cuttlefish have pupils that look like the letter "W," and dolphins have pupils shaped like crescents. Some frogs have heart-shaped pupils, while geckos have pupils that look like pinholes arranged in a vertical line.

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Needless to say, scientists want to know why all these different shapes evolved. "It's been an active point of debate for quite some time," says Banks, "because it's something you obviously observe. It's the first thing you see about an animal — where their eye is located and what the pupil shape is."

For their recent study, Banks and his colleagues decided to keep things simple. They looked at just land animals, and just three kinds of pupils. "We restricted ourselves to just pupils that are elongated or not," Banks explains. "So they're either vertical, horizontal or round."

The researchers gathered information on 214 species. They noted the pupil shape and the location of the eyes on the head, plus the animal's lifestyle. For example, was it predator or prey, and active during the day or night?

One of the researchers, Bill Sprague, also at the University of California, Berkeley, says some animals have such dark eyes, it's hard to even see the pupil.

An Akhal-Teke horse, from Turkmenistan, has horizontal slits for pupils, while the Mediterranean house gecko has vertical slits that look like a series of pinholes.


"I remember one in particular was the hyena," says Sprague. "It actually has a vertical pupil but it's very difficult to judge unless you work with them."

When they pulled everything together, a clear pattern emerged. In the journal Science Advances, the scientists report that there's a strong link between the shape of an animal's pupil and its way of life.

"If you have a vertical slit, you're very likely to be an ambush predator," says Banks. That's the kind of animal who lies in wait and then leaps out to kill. He says these predators need to accurately judge the distance to their prey, and the vertical slit has optical features that make it ideal for that.

But that rule only holds if the animal is short, so its eyes aren't too high off the ground, Sprague says.

"So for example foxes, in the dog lineage, have vertical pupils, but wolves have round pupils," he says.

And while a small pet cat has vertical slits, Sprague says, "the larger predators, like lions and tigers, have round pupils."

In general, round pupils seem to be common in taller hunters that actively chase down their prey, says Banks.

Meanwhile, he says, if you're the kind of animal that gets hunted, "you're very likely to have a horizontal pupil" and to have your eyes on the side of your head. That makes sense, he says, because it gives prey animals a panoramic view, so they can best scan all directions for danger.

But then the scientists began to wonder. This trick would only work if the animal's pupils were parallel with the horizon. And creatures like horses and sheep are constantly pitching their heads down to graze. When the researchers went to watch the animals in action, they discovered something unexpected.

"When they pitch their head down, their eyes rotate in the head to maintain parallelism with the ground," says Banks. "And that's kind of remarkable, because the eyes have to spin in opposite directions in the head."

"I've spent a lot of time handling horses, and having them put their head down to eat, and up to look around, and so on, and I had never noticed this," says Jenny Read, a vision scientist at Newcastle University in the United Kingdom. "It's just an ordinary observation that anyone could make, and yet apparently it wasn't known to science."

Read wasn't on the research team, but she says its conclusions seem right to her. "I think they're the first people to come up with a convincing explanation," she says, "for why the orientation should be chosen differently depending on your ecological niche."

Now, all of this isn't just important to scientists. Novelists and movie-makers constantly have to imagine the pupil shape of fictional creatures like Lord Voldemort in Harry Potter, or the dinosaur Indominus Rex in Jurassic World.

Giving their eyes vertical slits may make them look nice and evil, but Read says "I think their paper suggests that's unrealistic, because both of those creatures are sufficiently high off the ground that they probably should have round pupils."

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Men Looking To Get Ripped Are At Risk Of Abusing Legal Supplements

NPR Health Blog - Fri, 08/07/2015 - 1:37pm

Turning to over-the-counter supplements to get ripped can contribute to physical and psychological issues.


Men who work out may be using legal over-the-counter supplements to the point that it's harming their emotional or physiological health, according to a recent study.

The preliminary study, presented Thursday at the American Psychological Association's annual convention, recruited 195 men ages 18 to 65 who went to the gym at least twice a week and regularly consumed legal appearance- or performance-enhancing supplements — things like whey protein, creatine and L-carnitine.

Participants answered questions about their supplement use as well as their self-esteem, body image, eating habits and gender roles.

"The heyday for illicit supplements for the average man is over," says Richard Achiro, lead author of the study and a registered psychological assistant at a private practice in Los Angeles. "The bulky Arnold Schwarzenegger and Sylvester Stallone are not what most men are seeking to achieve now. They want to be both muscular and lean, and it makes sense that [legal supplements] are what they're using or abusing."

Forty percent of participants, who were all men, increased their supplement use over time, while 22 percent were replacing regular meals with dietary supplements. Eight percent of participants were told by their physician to cut back on supplement use because of health side effects, and 3 percent were hospitalized for related kidney or liver problems, which can be caused by excessive use of protein powders and other supplements.

Men who used dietary supplements inappropriately also were more likely to have behaviors associated with eating disorders.

Achiro is no stranger to the culture of workout supplements. His interest was piqued when he noticed throughout college and graduate school how common it was for his male friends to use supplements before or after workouts.

"It became more and more ubiquitous," Achiro says. "Guys around my age who I knew — I'd go to their apartment and see a tub of some kind of [protein] powder."

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Not to mention that this has become a multibillion-dollar industry that's grown exponentially in the recent decade or so, he adds.

Achiro was surprised to find that most studies focused on illicit supplements such as hormones and steroids and gave little thought to the role of legal supplements, which are readily available at supermarkets and college bookstores.

One big factor behind supplement use is body dissatisfaction, the study found. The men internalize a particular set of cultural standards of attractiveness usually depicted by the media: healthy, muscular and lean, "like Zac Efron," says Achiro. And they're unhappy that their own bodies don't meet that ideal.

But the study also found that the men using supplements were more likely to feel gender role conflict, which Achiro explained as underlying insecurity about one's masculinity.

"This isn't just about the body," Achiro says, "What this is really about is what the body represents for these men. It seems that the findings in part [show] this is a way of compensating for their insecurity or low self-esteem."

Abusing whey protein and the like can also put gymgoers at risk for other health problems such as body dysmorphic disorder, also known as muscle dysmorphia, and related body image disorders.

"Body dysmorphic disorder used to be referred to as reverse anorexia," Leigh Cohn, a spokesman for the National Eating Disorder Association, says.

"Someone with anorexia will feel they need to continue to get thinner and lose weight. With bodybuilders, they act in the same kind of manner. They acknowledge that they're ripped, but are obsessed with certain body parts that they find inadequate. This drive for muscularity preoccupies them. Supplements serve them the same way diet products serve someone with an eating disorder," Cohn says.

For people affected by body dysmorphic disorders, this constant and compulsive behavior takes over their lives — they are constantly body-checking and can be unhappy, dissatisfied, or have low self-esteem.

"Think about competitive athletics on the high school and college level. Lots of these guys are encouraged by coaches and trainers to take these supplements," says Cohn. "This isn't thought of as a negative behavior but can have negative consequences."

The silver lining, Achiro points out, is that 29 percent of study participants knew that they had a problem of overusing supplements. But they might not be aware of possible underlying psychological factors.

"Guys think taking supplements is healthy, [they're] convinced it's good for them, [it's] giving them all kinds of nutrients they wouldn't be getting otherwise," says Cohn. "[This is] ignorance about what proper nutrition is."

It's also not unusual for people diagnosed with body dysmorphic disorder or its characteristics to also have a high incidence of depression, anxiety and alcoholism, Cohn adds.

Although the research is preliminary and has yet to be peer-reviewed, Achiro hopes his research puts the issue on the map and encourages researchers to replicate his work.

"This is just the very beginning. There're still tons to look at," he says.

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Hospitals Turn To Toyota To Make Care Safer And Swifter

NPR Health Blog - Fri, 08/07/2015 - 8:29am

Nursing attendant Tracie Bell helps manage patients at the ophthalmology clinic at Los Angeles County Harbor-UCLA Medical Center. The clinic created a color-coded system to reduce wait times for patients.

Anna Gorman/Kaiser Health News

Until recently, nurses at Los Angeles County Harbor-UCLA Hospital had to maneuver through a maze of wheelchairs, beds, boxes and lights to find surgical supplies in the equipment closet for the operating rooms.

But as public hospitals like Harbor-UCLA try to cut costs and make patients happier, administrators have turned to an unlikely ally: Toyota.

They are adapting the carmaker's production system to health care — changing longstanding practices such as how to store equipment, schedule surgeries and discharge patients. The philosophy, known as lean, depends on a continuous team effort to pare inefficiency and improve quality.

By using Toyota's methods as inspiration, the operating room staff at Harbor-UCLA was able to reorganize the closet — giving everything an assigned location and affixing easy-to-read labels — meaning nurses and doctors can now find what they need when they need it. This allows the team to mobilize more quickly.

"It saves time because they don't go looking for things — they know where they are," says Dawna Willsey, a clinical director at the hospital.

Private hospitals in places like Seattle and Wisconsin started using Toyota's system a decade or more ago. But the idea is newer to safety net hospitals — medical centers that historically have served large numbers of poor people. With the Affordable Care Act, these patients are gaining insurance coverage, and safety net hospitals are facing pressure to keep them from going elsewhere for care.

In California and elsewhere, some medical professionals have expressed skepticism that a process used to build cars can be translated into treating patients. Others are put off by the use of Japanese vocabulary in the hospitals' hallways, such as muda (waste) and jidoka (automation with a human touch). Still others doubt whether the changes are sustainable.

DeAnn McEwen, a health and safety specialist with National Nurses United, says lean management reduces nursing to a series of standardized tasks, as if nurses were robots applying nuts and bolts to identical patients.

"The problem with that is patients, of course, are not widgets and nurses are not robots," she says. "And nursing care is not a commodity but a service. It's a process that requires critical thinking and the application of judgment."

Research and experience from around the country, however, has shown that using Toyota's techniques in hospitals has can improve quality and safety for patients, says Kelly Pfeifer, director of high-value care at the California HealthCare Foundation. The foundation helped fund the project at Harbor-UCLA and four San Francisco Bay Area hospitals — San Francisco General Hospital, Contra Costa Regional Medical Center, San Mateo Medical Center and the Alameda Health System.

Changes inspired by the Toyota process have had direct, positive results, such as reducing the time patients spend at the hospital and decreasing medication errors, according to the foundation. They also have saved money. For example, reducing surgery cancellations at the San Mateo hospital saved nearly half million dollars, the foundation says.

Harbor-UCLA happens to be just a few miles from Toyota's U.S. sales headquarters in Torrance. After approaching the car maker for help, Harbor opened an office in 2013 dedicated to kaizen, the Japanese word for continuous improvement and a main tenet of the auto company's philosophy. Now, the hospital has a chief kaizen promotion officer, Susan Black, whose team is working closely with administrators, doctors, nurses, clerks and janitors to streamline and standardize everything it can.

Susan Black, chief kaizen promotion officer at Los Angeles County Harbor-UCLA Medical Center, reviews the quality and safety board in the ophthalmology clinic.

Anna Gorman/Kaiser Health News

"This is not a flavor of the month," Black says. "We have a real need to do better, to do more, improve our access and do it for less. That is part of our survival."

Toyota's strategy is based on making small changes that have a big impact, says Jamie Bonini, vice president of the Toyota Production System Support Center. Hospitals typically want to improve certain elements, such as medication error rates or appointment wait times.

Toshi Kitamura, a Toyota advisor, says he sees natural parallels between auto production and patient care. Organizing the equipment rooms and supply cabinets is the perfect example, he says.

"There was a clear translation," he says. "Just as in the hospital environment, in our environment ... we need to make sure we have all the tools and materials we need and we need to be able to find them quickly."

Unlike in a car plant, however, Kitamura says saving time can spare people pain and even save their lives.

Toyota officials say their philosophy has been honed over decades of quickly producing high-quality cars. The company's nonprofit arm, Toyota Production System Support Center, now provides consulting services to dozens of manufacturers, which pay a fee, and nonprofits, which don't.

At Harbor-UCLA, the effort started with an overhaul of the outpatient eye clinic. Administrators there say some patients were going blind while waiting for surgeries to be scheduled. And during clinic visits, some had to have their eyes dilated twice because they waited so long to see a doctor.

Working with Toyota, staff members picked up the pace: They created a system of color-coded folders so it became clear what patients were there for and who they needed to see. They stopped sending patients back and forth to the waiting room during their visits. They put a locked box in each exam room with prescription pads and other medications so doctors could spend more time with patients and less fetching what they needed to treat them.

"Before, it was total chaos," says Tracie Bell, a nursing attendant. "We had piles and piles of paper. With this new color-coded system ... it makes it a whole lot easier for us to do our jobs."

Within several months, staffers doubled the average number of new patients seen each day. In addition, the time patients spent at the clinic dropped from 4 1/2 hours to just over two. Surgeries also got scheduled more quickly.

Now, doctors and nurses at the primary care clinic downstairs are in the early stages of adopting Toyota's strategies.

This story is part of a reporting partnership between NPR and Kaiser Health News.

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Can A 32-Year-Old Doctor Cure Baltimore's Ills?

NPR Health Blog - Thu, 08/06/2015 - 3:26pm
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Leana Wen hands out awards to business owners for their efforts to support breastfeeding at the Baltimore City Health Department on Tuesday.

Meredith Rizzo/NPR

Neighborhoods in Baltimore are still struggling to recover from the riots that broke out following the funeral of Freddie Gray, who suffered a fatal injury to his spine while in police custody. In the aftermath of the unrest, we here at NPR spent many hours trying to understand the raw anger on display. We looked at police brutality, economic disparities and housing segregation in Baltimore.

Our conversations eventually led us to Leana Wen.

Wen, a 32-year old emergency physician, had become Baltimore's health commissioner just a few months earlier. With Baltimore leading the news day after day, she seized the moment to get her message out, including on this blog, where she has been an essayist.

She wrote about the health department's immediate response to the unrest, making sure hospitals were protected and that staff and patients could get to them, and that ensuring seniors could still get prescriptions when their pharmacies were looted and burned.

After calm was restored, she turned her focus to the city's more chronic issues. For years, she argued, Baltimore has been traumatized by poverty, violence and drug abuse, problems that can be treated through public health.

"We have to make the case that actually, everything comes back to health," she told us in May. "My hope is that we can really make Baltimore into a model for the rest of the country to follow when it comes to treating the core roots of our problems."

A man walks past a blighted building in the Penn-North neighborhood of Baltimore.

Patrick Semansky/AP

That left us wondering, does everything actually come back to health? If so, what can you accomplish in city government? And can a health commissioner really make a difference?

Starting today, we're going to try to answer those questions. We're following Leana Wen over the coming months as she takes on some of Baltimore's thorniest problems. One thing already clear is that she's in a hurry.

Deputy Commissioner Olivia Farrow, a veteran at the health department, laughs remembering how Wen was holding meetings before she'd even officially started the job.

"Someone was telling me a joke," she says. "It's not 'Wen,' it's 'Went.' I mean, she's already ahead of you and gone, trying to make the fix."

New to Baltimore, Wen is relying heavily on Farrow and other senior staff to help her navigate the often murky politics of the city. Farrow believes Wen's lack of political experience is a plus.

"There's something about people who come from the outside," she says. "Just their ability to kind of say, 'Hey, let's think about things differently.' A lot of times that can rub people the wrong way. Some people survive that and some people don't."

Wen chats with a member of her staff at the Sandtown Winchester Senior Center.

Meredith Rizzo/NPR

Leana Wen was born in Shanghai and came to the United States at the age of 8. Her parents were Chinese dissidents who sought political asylum here, first landing in Logan, Utah, and a couple of years later moving on to Los Angeles. They lived in Compton and East Los Angeles, neighborhoods Wen describes as not so different from the poorer parts of Baltimore.

As a child, she dreamed of becoming a doctor. She entered college at the age of 13 and majored in biochemistry. After medical school, however, she was confronted by a sad reality. In the emergency room you can resuscitate victims of gun violence and overdose, she found, but you can't prevent them from returning over and over again.

"It is not a satisfying cycle for us to be in, when we're treating problems at the very end of those problems, rather than preventing them from happening in the first place," she recently told her staff.

Wen speaks during an ice cream social at the Sandtown Winchester Senior Center in Baltimore on Tuesday.

Meredith Rizzo/NPR

This summer, homicides in Baltimore have soared to levels not seen in four decades. The heroin epidemic is showing no sign of abating, and throughout the city there is a sense of frustration that no matter what happens, and no matter how many leaders speak out, nothing changes.

So Wen is asking her team to think big, to come up with innovative approaches to these festering problems. She believes that given all the focus on Baltimore since the death of Freddie Gray, this is a rare opportunity to act.

"I don't want that window of opportunity to close for us," she says. "I don't want to be the person who isn't leading us toward this vision at a time that's so critical in Baltimore's history."

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States Haven't Embraced Later School Start Times For Teens

NPR Health Blog - Thu, 08/06/2015 - 1:03pm

Maybe she goes to school in Wyoming, where no schools start after 8:30 a.m.


Here's a number to help frame the debate over whether middle schools and high schools should start later in the morning: A study finds that only 18 percent of these public schools start class at 8:30 a.m. or later, as the American Academy of Pediatrics recommends.

The figure comes from a U.S. Department of Education survey conducted in the 2011-12 school year, so it predates the 2014 AAP recommendation for a later starting time. But assuming the situation hasn't changed much, most schools are not accommodating the sleep needs of teenagers.

Countless PTA meetings and school board sessions have been devoted to appropriate start times for schools. Public health officials say teenagers need more than eight hours of sleep a night, and early start times stand in the way.

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"Obtaining adequate sleep is important for achieving optimal health," epidemiologist Anne Wheaton of the Centers for Disease Control and Prevention and her colleagues write in the latest Morbidity and Mortality Weekly Report, published Thursday. "Among adolescents, insufficient sleep has been associated with adverse risk behaviors, poor health outcomes and poor academic performance."

But changing the starting time for schools isn't so easy. Bus fleets that serve children from elementary to high school have to be scheduled to accommodate more than just the sleep-deprived teenagers. Later starts also push after-school activities later into the day — and potentially into dark winter evenings.

This survey finds that the push for later starting times has a long way to go. The survey of nearly 40,000 public middle schools and high schools found that only 17.7 percent started at 8:30 a.m. or later. High schools alone were even worse, with just 14.4 percent starting at 8:30 or later.

The northerly states of Alaska and North Dakota led the state-by-state tally published in MMWR, with nearly 80 percent of high schools and middle schools starting class after 8:30. The early bird states included Hawaii, Mississippi and Wyoming, where not a single school in the survey started later than 8:30 in the morning.

Teenagers are biologically inclined to stay up later, so early school starts generally cut short their sleep, the CDC report notes. Parents can help teens get more sleep by enforcing earlier bedtimes, the report suggests, and by limiting the use of TVs, game consoles, smartphones and other screens in the bedroom (which parents know is far more easily said than done).

"Among the possible public health interventions for increasing sufficient sleep among adolescents, delaying school start times has the potential for the greatest population impact," the study notes.

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Patients In Iowa Worry About Private Management Of Medicaid

NPR Health Blog - Thu, 08/06/2015 - 12:02pm
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Brenda Hummel and her 7-year-old daughter Andrea in their home near Des Moines, Iowa. Andrea was born with severe epilepsy and gets her health care through Medicaid.

Clay Masters/Iowa Public Radio

Brenda Hummel's 7-year-old daughter Andrea was born with severe epilepsy. Like many children with significant diseases or disabilities, she has health insurance through Medicaid. Hummel navigated Iowa's Medicaid resources for years to find just the right doctors and care for her daughter. But now Iowa's governor, Republican Terry Branstad, is moving full speed ahead with a plan to put private companies in charge of managing Medicaid's services, and that has Hummel worried.

Everywhere in the Hummel household, there are signs of just how much care Andrea needs. Her bedroom, for instance, looks like a typical kid's room — stuffed animals, a frog light that shines images on the ceiling, and a butterfly mobile. But the bed stands out – the head of the bed goes up and down so Andrea can have her head elevated when she sleeps.

Shots - Health News Iowa Opens The Doors To Medicaid Coverage, On Its Own Terms

"When she was throwing up all the time when she was in a regular bed, I hardly got any sleep," Hummel explains, "because if I heard her coughing, I knew she was choking."

Andrea has this bed thanks to Medicaid — as well as her wheelchair and nurses, like Nate Lair who's been with the family for years. When Hummel gets home from work, Lair says, Andrea's personality changes.

"That's when she turns on the diva attitude," he says, laughing.

That diva attitude is significant progress. For years, Hummel says, her daughter showed very little personality. Seizures interrupted her development.

Now Andrea is able to go to school and do normal activities. But her mom worries that having a private business in charge of Medicaid will jeopardize the level of care Andrea gets.

"She hasn't been in the hospital for 2 1/2 years, I think," says Hummel. "So when they look at that, they may think, '[Her services] are not medically necessary. She's doing great and doesn't need these services that are costing money.' But, in my eyes, she can fall back to having seizures any time. We're not out of the woods at all."

Maybe it'll be OK, Hummel says, but she just doesn't know enough.

Medicaid serves a large population in Iowa. The state expanded Medicaid under the Affordable Care Act, and is now open to not only its traditional population — the poor and disabled — but also to adults who earn as much as about $16,000 a year for a single person, and as much as $32,000 for a family of four.

Amy McCoy, who is with Iowa's Department of Human Services, says patients will continue to receive the same care under the new system, and the changes will save money and streamline the services.

Iowa Senate President Pam Jochum wants to make sure the transition of Medicaid recipients to private companies has good oversight.

Clay Masters/Iowa Public Radio

"Some people might have five doctors," McCoy says. "Through this care-coordination effort, they can make sure everybody's on the same page with their treatment."

McCoy says having private insurers manage Medicaid is nothing new.

"Thirty-nine states are using some kind of managed care," she says. "So other people have done this. We have models to look after, and we have companies who have experience."

But a lot of states, including Kansas and Kentucky, have not done so well, says Pam Jochum, president of the Iowa Senate and a Democrat.

"You know, when I was a kid growing up my mother would say, 'If everybody jumps off the bridge, are you going to, too?' " Jochum says. "Of course not! The point is that just because everyone else is doing it doesn't make it better."

Families like Brenda Hummel's have a natural ally in Jochum; she, too, has a daughter with special needs who has been on Medicaid all of her life. Still, even with Jochum's opposition to the changes in Medicaid, the process in Iowa is moving forward. Gov. Branstad did not need legislative approval when he announced the switch to managed care in January.

In response, some lawmakers, including Jochum, insisted on a committee to oversee the transition and to make sure that consumers are treated fairly.

"There is no way," Jochum says, "you can put that many people into a system all at once, with various degrees of disabilities and need, and think anyone can manage that and manage it well."

Shots - Health News Health Insurance Startup Collapses In Iowa

Eleven companies have submitted bids to manage most of the $4 billion program, and Iowa plans to announce later this month which insurers will win the bid.

Brad Wright studies health policy at the University of Iowa. He says a lot of states have experimented with this idea, but on a smaller scale.

"They've not ... done what Iowa is proposing to do — or at least most have not done this — which is to put everyone into it," Wright says.

The only hurdle that stands in the way of approval, he says, is an OK from the federal government.

"If that happens," Wright says, "starting in January, it's full steam ahead."

This story is part of NPR's reporting partnership with local member stations and Kaiser Health News.

Copyright 2015 Iowa Public Radio. To see more, visit
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On Yelp, Doctors Get Reviewed Like Restaurants — And It Rankles

NPR Health Blog - Thu, 08/06/2015 - 5:00am
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Patient reviews of doctors tend to focus on non-medical issues like wait time, billing and front office staff.

Mahafreen H. Mistry/NPR

Dental patients really don't like Western Dental. Not its Anaheim, Calif., clinic: "I hate this place!!!" one reviewer wrote on the rating site Yelp. Or one of its locations in Phoenix: "Learn from my terrible experience and stay far, far away."

In fact, the chain of low-cost dental clinics, which has more Yelp reviews than any other health provider, has been repeatedly, often brutally, panned in some 3,000 online critiques — 379 include the word "horrible." Its average rating: 1.8 out of 5 stars.

Patients on Yelp aren't fans of the ubiquitous lab testing company Quest Diagnostics, either. The word "rude" appeared in 13 percent of its 2,500 reviews (average 2.7 stars). "It's like the seventh level of hell," one reviewer wrote of a Quest lab in Greenbrae, Calif.

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Indeed, doctors and health professionals everywhere could learn a valuable lesson from the archives of Yelp: Your officious personality or brusque office staff can sink your reputation even if your professional skills are just fine.

"Rudest office staff ever. Also incompetent. I will settle for rude & competent or polite & incompetent. But both rude & incompetent is unacceptable," wrote one Yelp reviewer of a New York internist.

ProPublica and Yelp recently agreed to a partnership that will allow information from ProPublica's interactive health databases to begin appearing on Yelp's health provider pages. In addition to reading about consumers' experiences with hospitals, nursing homes and doctors, Yelp users will see objective data about how the providers' practice patterns compare to their peers.

As part of the relationship, ProPublica gets an unprecedented peek inside Yelp's trove of 1.3 million health reviews. To search and sort, we used RevEx, a tool built for us by the Department of Computer Science and Engineering at the NYU Polytechnic School of Engineering.

Though Yelp has become synonymous with restaurant and store reviews, an analysis of its health profiles shows some interesting trends. On the whole people are happy — there are far more 5-star ratings than 1 star. But when they weren't, they let it be known. Providers with the most reviews generally had poorer ratings.

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Of the top 10 most-reviewed health providers, only Elements Massage, a national chain, and LaserAway, a tattoo and laser hair removal company with locations in California and Arizona, had an average rating of at least 4 stars.

Western Dental did not return phone calls and emails seeking comment.

Dennis Moynihan, a spokesman for Madison, N.J.-based Quest Diagnostics, said the company has more than 2,200 patient service centers around the country and had 51 million customer encounters last year. He said all feedback is valued.

"While one negative customer experience is one too many, we don't believe the numbers presented are representative of the service that a vast majority of our customers receive every day," he said.

For years, doctors have lamented the proliferation of online rating websites, saying patients simply aren't equipped to review their quality and expertise. Some have gone so far as to threaten — or even sue — consumers who posted negative feedback.

But such reviews have only grown in popularity as consumers increasingly challenge the notion that doctor knows best about everything. Though Yelp's health reviews date back to 2004, more than half of them were written in the past two years. They get millions of page views every month on Yelp's site alone.

In many ways, consumers on Yelp rate health providers in the same way they do restaurants: on how they feel they've been treated. Instead of calling out a doctor over botched care or a possible misdiagnosis (these certainly do happen), patients are far more likely to object to long wait times, the difficulty of securing an appointment, billing errors, a doctor's chilly bedside manner or the unprofessionalism of the office staff.

Health providers as a whole earned an average of 4 stars.

But sort by profession and the greater dissatisfaction with doctors stands out.

Doctors earned a lower proportion of 5-star reviews than other health professionals, pushing their average review to the lowest of any large health profession, at 3.6. Acupuncturists, chiropractors and massage therapists did far better, with average ratings of 4.5 to 4.6.

Other providers, like dentists and physical therapists, are "actively seeking out customers to review them, whereas doctors have a lot of antipathy toward reviews and as a result have been trying to suppress reviews for many years," said Eric Goldman, a professor at Santa Clara University School of Law and co-director of its High Tech Law Institute. He has written extensively about physician review websites and physician arguments against them, but did not review the Yelp data.

Doctor visits also tend to be more complex than visits to the dentist or chiropractor. A typical dental visit is for a specific service — a teeth cleaning, a cavity filled or a root canal. In general, expectations are clear, and ways to gauge success are easier than with a doctor visit.

Healthgrades, a site which focuses solely on health providers, also sees slightly lower ratings for doctors than for dentists and other health providers, though the differences are smaller than those on Yelp.

Unlike Yelp, Healthgrades, which says it has 6 million survey scores, has not allowed consumers to post comments. But Evan Marks, Healthgrades' chief strategy officer, said the health rating systems are in their infancy. Soon, he said, patients could see different questions based on the type of doctor they see to provide far more useful feedback to those searching the site.

None of this has yet gained favor with physicians. The American Medical Association encourages patients to talk to their doctors if they have concerns, not post views anonymously. And those looking for doctors should be similarly skeptical, the group says in a statement. "Choosing a physician is more complicated than choosing a good restaurant, and patients owe it to themselves to use the best available resources when making this important decision."

The AMA has called on all those who profile physicians to give the doctors "the right to review and certify adequacy of the information prior to the profile being distributed, including being placed on the Internet."

In 2012, the group partnered with a company called to offer discounts to doctors for a service that monitors their online presence and tries to combat negative reviews.

Western Dental's average rating of 1.8 stars on Yelp is well below the average of 4 for all dentists nationwide. About 1,250 of its 3,000 reviews used the words "wait" or "waiting" and about 15 percent of them, the word "worst."

When patients leave angry comments, the chain's "social media response team" often replies, inviting patients to call or email and citing a federal patient privacy law known as HIPAA for not responding in more detail. "Thank you for reaching out and providing the opportunity to improve our services. We hope to speak with you soon," the notes say.

At least one patient gave a Yelp follow-up review of the social media response team's performance: "I responded to the info in their response twice and got no reply at all ... they are just attempting to minimize the PR damage caused by undertrained and rude, lazy staff."

Periodically doctors, dentists and other providers threaten or even file lawsuits against people who post negative reviews on Yelp or against Yelp itself. Their track record is poor: Courts have ruled in favor of the company and various consumers.

In June, New Jersey resident Christina Lipsky complained in a 1-star review on Yelp that Brighter Dental Care had recommended $6,000 worth of work that a another dentist subsequently determined was unnecessary.

Within days, she received a letter from a lawyer who said he was retained by Brighter Dental "to pursue legal action against you and all others acting in concert with you." The letter was signed by Scott J. Singer, an attorney whose office is in the same building as a Brighter Dental clinic. A man named Scott Singer was also listed in 2012 as the non-clinical chief executive officer of Brighter Dental. Singer did not return a call or email seeking comment.

After Lipsky took her story to local media, Singer sent her a letter saying Brighter Dental was dropping its legal pursuit. In an email to ProPublica, Lipsky said "People put a lot of trust into their health care providers, and if my review could help others make an informed decision regarding their treatment, then it was worth it."

Charles Ornstein is a senior reporter at ProPublica, an independent nonprofit newsroom.

Copyright 2015 ProPublica. To see more, visit .
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Sharing Art Helps Medical Students Connect With Dementia Patients

NPR Health Blog - Wed, 08/05/2015 - 4:11pm

A New York study found that getting medical students together with dementia patients and their families at museums to view, discuss and create art for 90 minutes made the students better communicators.

Colin Hawkins/Getty Images

Hannah Roberts was a first-year-medical student at Columbia University College of Physicians in 2013 when she noticed her classmates were having an especially tough time relating to dementia patients.

"There's a misconception that dementia patients are like toddlers in a way," Roberts says. Many medical students, she says, "are intimidated at the challenge of having to get accurate histories and establish a connection with someone who has a limited ability to communicate."

Inside Alzheimer's

Roberts had some previous work experience with Alzheimer's patients and knew the encounters didn't have to be so strained. "These are adults who've led full rich lives, who have lots of knowledge and personalities that are still very present," she says. But that's not always initially apparent "unless you dig a little."

Could a field trip together to the local art museum help?

Roberts and one of her teachers, Dr. James Noble, a neurologist at Columbia University Medical Center, suspected it might. The results of their small study, recently published online in the medical journal Neurology, suggests they may be on to something important.

Noble has been interested since 2009 in how Alzheimer's patients express themselves through art. He noticed in other art programs aimed at patients and their families that discussing and making art can cement emotional connections and transform relationships in other ways.

"An adult son would be sitting next to their mom and dad; something would be said, and the son would suddenly realize his father could still do more than he thought possible," Noble says.

Noble went on to start his own nonprofit, called Arts & Minds, to provide museum-based experiences for people with dementia and their caregivers. The program has been running in the Studio Museum in Harlem for about five years and at the New York Historical Society for roughly three years.

But the idea of bringing medical students along was something new.

Roberts and Noble recruited 19 medical students for their study. Students, family and patients gathered in a gallery or museum to view, discuss and create art together for 90 minutes.

Before and after the session, the medical students completed the standardized Dementia Attitudes Scale survey, answering 20 questions about their comfort level and knowledge of dementia. They were asked to rate statements such as, "I feel confident around people with Alzheimer's diseases and related disorders" or "people with Alzheimer's disease and related disorders can enjoy life."

The students' scores afterward suggested a "modest increase" in comfort level in dealing with dementia patients, the researchers say, but the students' comments suggested the lessons ran even deeper.

"It gave us a chance to interact with patients with dementia in a context where their dementia isn't the main focus," one student told the researchers. "We get to see what they are capable of — more so than what they are incapable of — which so often is what cognitive tests force a patient to do."

"It's frightening to take care of someone you don't understand," says Marcia Childress, associate professor of medical education at the University Of Virginia School Of Medicine. Childress wasn't involved in the Columbia study but co-wrote an editorial about the experiment in the same issue of Neurology.

"It's important for students to see people with chronic illnesses that affect their function and daily life and to see them outside a clinical setting," Childress says. "What is it like to be housebound? What is it like to be the caregiver — to see this and appreciate the burden."

Such lessons are only getting more important. An estimated 5.3 million Americans have Alzheimer's disease, with the number of cases steadily rising.

Will this changed perspective among the students last?

"We don't know," says Noble. But he sure hopes so and plans to follow up.

Copyright 2015 NPR. To see more, visit
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HIV Prevention Pill Remains A Tough Sell Among Gay Latinos

NPR Health Blog - Wed, 08/05/2015 - 1:09pm

Louis Arevalo holds his Truvada pills at his home in Los Angeles. The drug can be over 90 percent effective at preventing spread of HIV.

Heidi de Marco/Kaiser Health News

At the New Jalisco Bar in downtown Los Angeles, a drag show featuring dancers dressed in sequined leotards and feathered headdresses draws a crowd on a Friday night, most of them gay Latino men.

Inside the bar and out, three health workers chat with customers, casually asking questions: Do you know about the HIV prevention pill? Would you consider taking it? A few men say they have never heard of it. Others simply say it isn't for them.

"It hasn't really hit the Latino community yet," Jesse Hinostroza, an HIV prevention specialist with AltaMed health clinics, says while sitting at a table with a bowl of condoms and a stack of bilingual pamphlets about the pill. "They aren't educated about it."

In California, New York, Texas and elsewhere, health workers are trying to get more high-risk Latino men to use the drug, Truvada. AltaMed's efforts are being paid for by Gilead, the pharmaceutical company that makes Truvada.

The medication, which is used for "pre-exposure prophylaxis," or PrEP, was approved by the FDA in 2012 for HIV prevention and has been shown to be more than 90 percent effective when used correctly. But health workers are encountering barriers among Latinos.

Those barriers include a lack of knowledge about the drug, and the stigmas attached to sleeping with men and to perceived promiscuity. Many Latinos also have concerns about costs and side effects.

"Even for people who have heard about it, [these concerns make] them reluctant to use, or hesitant to even inquire about, it," says Phillip Schnarrs, assistant professor of health promotion at the University of Texas at San Antonio and research director for the Austin PrEP Access Project.

Schnarrs, who is conducting a study with gay and bisexual Latino men in Texas, says 58 percent of those surveyed see themselves as good candidates for PrEP, compared with 82 percent of non-Hispanic whites, according to preliminary data.

In an ongoing study of 20 Latino gay couples in New York City, 37 of the 40 people had never heard about PrEP when interviewed last year, says Omar Martinez, assistant professor of social work at the Temple University College of Public Health.

Martinez says doctors and health workers need to focus on reaching young minority men at highest risk of getting HIV and transmitting it to others, including those who don't regularly use condoms.

"We need to do something," he says. "And PrEP may be the solution."

Latinos are disproportionately affected by HIV. They make up about 21 percent of new infections nationally, though they represent about 17 percent of the population, according to the Centers for Disease Control and Prevention. Latinos are also more likely than non-Hispanic whites and blacks to get diagnosed later in the course of their illness, raising the risks to their health and the likelihood of transmission to others.

At the same time, Latinos are less likely than non-Hispanic whites to be insured or have a regular doctor, although the Affordable Care Act has helped reduce that gap.

Truvada can cost up to $1,300 a month. Most insurance companies and Medicaid programs are covering at least part of that, and many local governments are also covering the pill for uninsured residents. But the high sticker price can dampen interest among patients.

Truvada, which blocks the virus from spreading in the body, is helping to significantly reduce new infections, says Robert Grant, a professor at the University of California, San Francisco School of Medicine who leads research on PrEP's effectiveness.

But the pill does not protect against other sexually transmitted diseases, requires daily use and can cause side effects in some patients, including kidney problems.

"It is a very valuable option, but it is only one option," Grant says. "Condoms are still a very important part of a sexual health strategy."

Back at the New Jalisco Bar, while customers dance to traditional Mexican music beneath a disco ball and rainbow lights, Jaime Cardenas conducts HIV tests in a mobile unit parked in front. Anyone who tests on the spot receives a free drink coupon, courtesy of AltaMed and the bar.

One of the first to agree is Erik Quezada, 35, a counselor at a Los Angeles high school. Cardenas draws a few drops of blood and within minutes gives Quezada the good news: He doesn't have HIV. Cardenas quickly follows up with information about the HIV prevention pill. Quezada says he has heard it's like a birth control pill for gay people. He agrees to be contacted by phone but quickly adds, "I don't know I would ever sign up for it."

Erik Quezada, 35, says he has heard Truvada is like the birth-control pill for gay people. Quezada, a counselor at a Los Angeles high school, says he's not sure he would sign up for it.

Heidi de Marco/Kaiser Health News

Others are even less interested. Jose Arriola, 25, a self-described "diva," says he doesn't want to take any medication. "It's better to use condoms," he says, sitting by his boyfriend at the bar.

A short video produced by AltaMed plays between acts at the bar. The video features different Latino men getting dressed: a cowboy for a night out, a day laborer for work, a buff young man for the gym. Each takes the HIV-prevention pill as part of their routine.

"We are really trying to project the message that taking PrEP can be a normal part of your everyday life," says Dr. Scott Kim, medical director of HIV Services for AltaMed, which runs more than 40 health clinics in Southern California.

That, he hopes, will reduce stigma. Kim says health workers need to be more creative in places like East Los Angeles, where many gay and bisexual Latinos are still in the closet and aren't getting information through traditional health-care sources. Talking about PrEP at a doctor's office may not be as effective as doing so on social media, by text message or in a bar, he says.

"There are a lot of social obstacles and challenges we have to negotiate here because it's harder to be out," Kim says.

The goal of Gilead's $80,000 grant to AltaMed is to help 100 high-risk gay Latino men throughout Los Angeles County get prescriptions for PrEP. The grant pays for the outreach but does not cover the cost of the medication.

Since the project began late last month, about half a dozen patients have received prescriptions. Hinostroza of AltaMed says there is more interest and more knowledge in gay-friendly Hollywood and West Hollywood.

"But for East Los Angeles, where we are, it's a struggle," she says.

Louis Arevalo, 27, a college student and AltaMed patient who lives in Los Angeles, says he decided to go on the medication last month after getting scared when a condom broke. But Arevalo says he understands the stigma that might prevent others from taking the drug. For years, he says, he has hidden his boyfriends from his mother, an immigrant from El Salvador. Arevalo says her church pastor repeatedly says that homosexuality is a sin.

Louis Arevalo, 27, says he decided to go on the medication last month after getting scared when a condom broke. The college student from Los Angeles says he uses the pill as an extra layer of protection.

Heidi de Marco/Kaiser Health News

"It's just part of the culture, and it's the religion," he says.

AltaMed's efforts are just one part of a larger effort to get the word out about Truvada. The nonprofit Latino Commission on AIDS, based in New York, also recently started a campaign in five cities — Long Beach, Calif.; New York City; Chicago; Miami; and San Juan, Puerto Rico.

Gustavo Morales, the commission's director of access to care services, says now is the time to educate people about PrEP, lest too many people form negative opinions about it and health workers become "like salmon swimming against the current."

Morales says patients aren't the only ones who need more information. When he decided to go on PrEP late last year, he went to two different doctors who didn't know about Truvada. A third asked him why he wanted to poison himself. Finally, he got a prescription from an HIV specialist.

"I was definitely disappointed," says Morales. "There is a lot of work that still has to be done."

This story is part of a reporting partnership between NPR and Kaiser Health News.

Copyright 2015 Kaiser Health News. To see more, visit
Categories: NPR Blogs

Untangling The Many Deductibles Of Health Insurance

NPR Health Blog - Wed, 08/05/2015 - 6:08am
Illustration Works/Corbis

Sure, there's a deductible with your health insurance. But then what's the hospital deductible? Your insurer may have multiple deductibles, and it pays to know which apply when. These questions and answers tackle deductibles, whether an ex-spouse has to pay for an adult child's insurance, and balance billing.

Recently I took my son to see a pediatric gastroenterologist. When I arrived at the office, I saw it was located adjacent to the hospital. My insurance has a large hospitalization deductible so I worried that the visit would not be covered. Nobody in the office could tell me how much an office visit would cost. Why not? Isn't that something I should be able to expect?

Your plan's hospital deductible won't affect how much you pay for the visit to the specialist, whether or not his office is affiliated with the hospital, says Richard Gundling, vice president at the Healthcare Financial Management Association, a professional group.

Here's how it works. Most health plans have medical deductibles that must be satisfied before the plan starts paying for most services. Preventive care is an important exception; there's no deductible for that. Some plans like yours also have separate hospital deductibles. But your hospital deductible would generally only come into play if you were admitted as an inpatient.

"Even if the facility is hospital based, her visit would still be an outpatient procedure and wouldn't affect her hospital deductible," Gundling says.

Though your hospital deductible wouldn't be an issue in this case, if your plan has a regular medical deductible and you haven't yet satisfied it for the year, you may have to pay for the specialist visit anyway.

The doctor's office should have been able to tell you how much the office visit would cost, Gundling says, but you may be better off checking with your insurer to find out how much you'll actually owe out of pocket. Your insurer will have information about both how much it has agreed to pay the provider for an office visit and how much you'll owe based on your health plan deductible and copayment details.

I have insurance coverage through the Affordable Care Act's marketplace. When I visited a cancer clinic for a routine blood check, I asked upfront three times (first over the phone and again when I was there) if all services would be in-network. The answer was yes each time. Afterward I received a bill from an out-of-network lab for $570. Is there anything I could have done to avoid this charge?

In theory, you could have asked the clinic for the name of the lab that it would use for your blood work and checked with your insurer to make sure that it too was in network, says Kevin Lucia, a senior research fellow at Georgetown University's Center on Health Insurance Reforms who co-authored a recent study on state efforts to protect consumers from surprise out-of-network bills.

However, "that seems to be a lot of work for the consumer," Lucia says.

New rules take effect next year for plans sold on the marketplace that will require health plans to maintain up-to-date lists of providers that are easily accessible to consumers.

A CMS official was unable to clarify whether plans must also provide up-to-date listings of labs in addition to other providers.

In the meantime, check with your insurer, Lucia advises. It's not unusual for providers to bill patients for services that are ultimately covered by their plan.

My ex-husband is responsible for health care premiums for our dependent daughter who will turn 21 in October. Under the Affordable Care Act, children can remain on their parents' plans until age 26, but my ex is planning to drop our daughter's coverage when she turns 21. Can he do that?

Yes, he probably can. Although the law requires health plans to offer coverage until adult children turn 26 in most instances, there's nothing that requires parents to provide it. If your divorce agreement required him to pay for your daughter's health insurance until she turns 21, his obligation will likely be satisfied at that point.

If your ex-husband chooses to drop your daughter's coverage and she doesn't sign up for her own plan, however, he may be on the hook for any financial penalty she owes for not having insurance.

Under the health law, most people have to have insurance or face penalties. In 2015, the penalty is the greater of 2 percent of household income or $325 per person.

If he claims her as his dependent, "When he does his taxes he'll have to show that everyone in his household has insurance, and then he'll have to pay the penalty," says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

Since she's part of his household, the penalty would be based on his income, not hers.

As for your daughter, if she loses coverage she'll be eligible for a special enrollment period to sign up on the exchange, or she may be eligible for Medicaid if she lives in one of the roughly two-thirds of states that have expanded coverage to adults with incomes up to 138 percent of the federal poverty level, currently $16,243.

Copyright 2015 Kaiser Health News. To see more, visit
Categories: NPR Blogs

Straighten Your Hair Without Frying It? Engineers Are On The Case

NPR Health Blog - Tue, 08/04/2015 - 2:00pm

It's the heat that straightens the hair. But too much, and hair can be permanently limp, or burned.


Heated tools like flat irons can make hair waterfall straight. But there's always that worry of burning the hair, or yourself.

That can make hair-straightening a miserable process, as Marita Golden wrote in her essay "My Black Hair":

"For generations of young Black girls, the family kitchen was associated with pain and fear, tears and dread. The kitchen was where, as a young girl, I got my hair 'straightened.' My coarse, sometimes called 'kinky' or 'nappy,' hair, which was considered 'bad' hair, got straightened with an iron comb that had been heated over a burner on the stove.

"My mother, like so many mothers, thought this was an art or a science, but in reality it was haphazard, even dangerous work when performed by amateurs."

Tahira Reid and Amy Marconnet work with Purdue University graduate student Jaesik Hahn, using an infrared microscope, to study how heat affects hair.

Purdue University image/Mark Simons

Engineers at Purdue University are trying to invent the science. Heat damage can make hair permanently straight, but not in a good way, says Tahira Reid, an assistant professor of mechanical engineering at Purdue. "The question we're trying to answer is, 'How much heat is too much heat before you lose your permanent curl pattern?' "

The problem is, when it comes to hair and heat, we don't know that much.

"There's a lack of data; not that many experiments have been done. There are few values we can compare to in [existing] literature," says Amy Marconnet, an assistant professor of mechanical engineering at Purdue. Reid came to Marconnet for her expertise in studying heat transfer, and the two partnered up to answer that question.

The team classified hair into eight standard types, from Type I to Type VIII, based on degree of curvature. Type I is straight to slightly wavy hair, Type II is hair with loose waves, and Type V is very curly hair. Type II is more typical of Caucasian hair, Marconnet says, while Type V is natural African-American hair.

A graduate student in Reid's lab, Jaesik Hahn, took a commercially available hair straightener — a flat iron with ceramic plates and temperature control — and attached it to a robotic arm. A computer controlled the robot to move swatches of hair through the appliance, repeatedly straightening while monitoring the temperature.

Their study, presented at the American Society of Mechanical Engineers' International Design Engineering Technical Conference on Monday in Boston, found that slightly wavy Caucasian hair conducts more heat than very curly African-American hair on both low and high temperature settings.

"We're one of the first groups, if not the first, to measure multiple types of hair," says Marconnet. "We can conclusively show how Caucasian hair and African-American hair performs differently."

Higher heat conductivity means the hair fiber spreads heat better, and makes it less likely that hair will be burned. Bottom line: Curly African-American hair might be more likely to suffer heat damage than straighter hair.

"It's like the handle on the pot," Marconnet explained, "[when] you have hot water in the pot, if it's a metal handle you wouldn't want to grasp the handle, but you would a plastic handle because it doesn't conduct the heat [as much]."

Hairdressers at the salon might know from experience what works best without damaging the hair, but the average consumer might not.

The Purdue team is working on finding threshold temperatures for different types of hair, quantifying the heat damage caused and looking at long-term effects of repeated flat-iron use. For now, the scientists' best advice is to be cautious when using flat irons to style hair.

Down the road they might also investigate permanent hair-straightening, different types of flat irons, and products that claim to protect hair from heat damage.

"Just looking at the number of different [hair] products on the market, all the different buzzwords, the market knows people want the ability to control their hair," says Marconnet. "We hope to put some science behind the products."

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Women, There's A Reason Why You're Shivering In The Office

NPR Health Blog - Tue, 08/04/2015 - 12:13pm

It may be August, but in the office it feels like January. And there's a mysterious man to blame.

Neil Webb/Getty Images/Ikon Images

He was probably about 40 years old, 155 pounds, white and wearing a suit. And he's the reason why women are shivering at their desks in air-conditioned buildings.

At some point in the 1930s, someone defined "metabolic equivalents" — how much energy a body requires while sitting, walking and running. Almost a century later, the back-of-the-envelope calculations are considered a standard for many things, including air conditioning.

But using that metabolic equivalent could be unnecessarily ramping up energy bills during summertime, researchers say, and it's time to plug in the right numbers so that air conditioning settings aren't biased toward men, and fewer women are reaching for the sweater.

"Garbage in, garbage out," says Boris Kingma, a biophysicist at Maastricht University in the Netherlands and lead author of the study, published Monday in the journal Nature Climate Change. "So, if you put in the wrong metabolic rate, you get an answer which is of course not valid."

Even while sitting quietly at a desk, the human body is working to keep everything running smoothly — the brain churning, blood flowing and vital organs at a cozy 98.6 degrees Fahrenheit. It has to work harder if the temperature isn't quite right.

"Basically if you are sitting in an office and the temperature is neutral, then your body is able to completely control or maintain core temperature only by changing skin blood flow," says Kingma.

If the temperature is just a little too cold, the body starts making tweaks to preserve heat. Vessels will keep blood closer to the body's core, leaving hands, feet and nose cold and pale. The person might feel the urge to grab a sweater or boil up some tea.

In general, women feel colder than men do at the same air temperature. They prefer rooms at 77 degrees Fahrenheit, while men prefer 72. Body size and fat-to-muscle ratios are largely to blame for that discrepancy.

"Fat cells produce less heat than muscle cells," explains Kingma, which is why women's higher fat-to-muscle ratio can make a difference. Plus women tend to be smaller than men, so "in general, women have a lower resting metabolic rate than males."

To determine a female metabolic equivalent, Kingma had 16 women in T-shirts and sweatpants hang out in a temperature-controlled room, and calculated the rate at which they were consuming oxygen and releasing carbon dioxide. It's a good measure of how much energy someone's generating. He found that their metabolic rates were significantly lower than the standard resting metabolic rate. So their bodies actually needed higher room temperatures to be comfortable.

This is just one of many studies over the years, from Japan to Finland, concluding that bodies of different sizes work really differently, depending on their dimensions, age and gender. Men and women of exactly the same size will produce different amounts of energy, because of slight variations in body function, skin surface area, organ size and fat distribution.

Even though the energy requirements between bodies vary only slightly, Kingma argues, they can affect energy use in unpredictable ways. "If you are feeling a bit cold, you might drink a cup of tea more," he says. "And boiling a liter of water takes really a large amount of energy."

There's no unified agreement on variations in metabolism among body types, says Bjarne Oleson, head of the International Center for Indoor Environment and Energy and professor at the Technical University of Denmark. What is clear is that Americans keep their buildings way too cold.

In the summer, international standards recommend temperatures between 73 and 79 degrees Fahrenheit. "But very often when you are in the U.S., they are between [68 to 73 Fahrenheit], which is really what we recommend for winter," says Oleson.

He thinks dress codes are more to blame for discomfort than temperature standards. "Women adapt much more their clothing in the summertime to the outside temperature than men do," says Oleson. But air conditioning is "operated so men in the business suit feel comfortable."

All this temperature talk might seem silly; just put on a sweater, right?

"But we know that temperature also influences your productivity," says Oleson. Uncomfortably chilly or hot offices can puncture concentration and increase errors in basic tasks like typing. Multiple studies have found that 72 degrees Fahrenheit is the best temperature for productivity and learning.

Cold air is also expensive. In 2005, to cut energy bills and help the environment, Japan's Ministry of the Environment introduced a special summer dress code and cranked up the temperature in government offices to 82 degrees. Similar efforts in South Korea, the U.K., and at the United Nations headquarters in New York seem to have wilted. But after a decade, Japan's "Cool Biz" campaign is still going strong.

Air conditioning temperature is just one standard that is coming under scrutiny as people start overhauling outdated standards based primarily on one body type.

"In some instances, it's a matter of life and death, like for automobile safety," says science historian Londa Schiebinger, who runs the Gendered Innovations project at Stanford. She says the standard of the 155-pound male body pops up all over engineering, biomedical and health research. It's one reason why car crash-test dummies had to be redesigned, and why some medicines were recalled as too dangerous for women.

Redesigning things to more accurately reflect the population, she says, can make life better for all, like when the cockpits of military aircraft were redesigned to fit female pilots, or when osteoporosis was reconsidered to include male patients.

"My suggestion here would be that all engineers, architects, urban planners, automobile designers go back and look at their standards," she says. Then ask: "What is the basic standard that things are engineered for? Who is the assumed ideal subject or user?"

And do they need a sweater?

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Is Obamacare's Research Institute Worth The Billions?

NPR Health Blog - Tue, 08/04/2015 - 5:03am

PCORI Executive Director Joe Selby says grants to medical societies are needed to get through to busy professionals who "may not answer our phone calls."

Stephen Elliot/Courtesy of PCORI

On the ninth floor of a glassy high rise in downtown Washington, partitions are coming down to make more room for workers handing out billions of dollars in Obamacare-funded research awards.

Business has been brisk at the Patient-Centered Outcomes Research Institute or, PCORI, as it is known. The institute was created by Congress under the Affordable Care Act to figure out which medical treatments work best —measures largely AWOL from the nation's health care delivery system.

Since 2012, PCORI has committed just over $1 billion to 591 "comparative effectiveness" contracts to find some answers, with much more to come. Money has thus far gone to researchers and medical schools, advocacy groups and even the insurance industry's lobbying group, which snagged $500,000.

Institute officials say they are reshaping medical research by stressing "patient centered" projects that offer practical guidance to people living with chronic diseases. They cite a $14 million study to settle the debate over how much aspirin people should take daily to help ward off heart disease, or the $30 million project to reduce serious, even deadly, injuries from falls in the elderly.

But like all matters rooted in Obamacare, there are sharp disagreements, both political and scientific, over the core mission of the independent institute. PCORI expects to spend $3.5 billion by the end of the decade. Then it expires.

On both the right and the left, there's simmering doubt about whether the unusual nonprofit can live up to expectations, or even what those expectations should reasonably be. Others argue these sorts of decisions should have been made prior to committing up to $3.5 billion.

"PCORI seems to have become almost invisible. Maybe they think that's the best way to stay under the political radar screen," said Gail Wilensky, a former Medicare chief under President George H.W. Bush. The institute has yet to "offer much value," she said.

Some Republicans are viscerally hostile. They want to kill off or at the very least hamstring the institute, fearing it will lead to rationing of medical care by interfering with medical decision-making.

The House Appropriations Committee in late June voted to cut PCORI's funding by $100 million—dubbing it wasteful spending. Earlier this year in the Senate, Kansas Republican Pat Roberts filed a bill to prevent Medicare from using PCORI results to "deny or delay coverage of an item or service."

"Americans do not want the federal government limiting their treatment options and deciding what is best for them," Roberts said at the time.

Liberals aren't singularly thrilled, either. They fault the institute for not evaluating enough drugs and medical devices head-to-head to see which offer the best results – and thus the biggest bang for the health-care buck.

"If it doesn't prove its worth soon there will be increasing calls for getting rid of it, or reducing its funding," said Topher Spiro, vice president for health policy at the Center for American Progress, a liberal think tank. "That concerns us."

PCORI executive director Joe V. Selby, a family physician and researcher, accepts some of the flak. But he argues that Congress directed the institute to explore research topics patients want and need — not to issue edicts on which treatments offer the best bargain.

"We are not in any way a cost effectiveness shop," Selby said in an interview. "That is not our job and there is a certain wisdom in saying that we shouldn't get involved."

Clearly, PCORI's stated mission means different things to different people.

Five years after setting up shop, PCORI is sponsoring many projects that offer great hope to doctors, patients and their advocates. But the institute also has spent hundreds of millions of dollars on activities only tangentially related to discovering which medical treatments are the most successful, a review by the Center for Public Integrity has found.

Among the findings:

  • PCORI has spent only about 28 percent of its contracting budget on projects that assess how best to prevent, diagnose or treat diseases. Selby says more such projects are coming, including head-to-head evaluations of drugs and medical and surgical treatments. He cited a hepatitis C study coming in the fall that will pit the highly costly drug Sovaldi against other options. Much of PCORI's other spending, though, concerns how to accelerate its research or improve health care systems.
  • More than $70 million in PCORI awards cover projects intended to improve methods for conducting research, or to pay for contracts that are essentially public relations gestures to build support and good will in the medical community.

Those figures include nearly $10 million in "engagement" awards and "meeting and conference" subsidies for medical societies and other groups. America's Health Insurance Plans, the industry trade group, got two engagement awards this year that total $500,000. One physicians' organization got $250,000 to find out what its members think about PCORI and its work.

Institute officials said these types of awards are necessary to get their work noticed and amount to a mere "rounding error" in terms of total money spent.

PCORI has allocated an additional $61 million to help spread the reach and impact of its activities. But some projects, at least in summaries posted on the institute's website, are so freighted with academic and scientific language that it's hard to imagine how they could attract a wide audience. One project, for instance, looks at how doctors can create a "Zone of Openness" with patients.

But the institute faces steep challenges in making its mark on the everyday practice of medicine. The Affordable Care Act states that PCORI's findings are "not to be construed as mandates for practice guidelines, coverage recommendations, payment or policy recommendations."

Some critics say that language handcuffs the institute by limiting how its findings can be put to practical use. Others argue that PCORI has plenty of authority to push for more efficient health care spending, but has been too timid in wielding that power.

The health reform law gives PCORI "more flexibility than it is willing to use," said Nicholas Bagley, who teaches at the University of Michigan Law School.

Oversight Is Minimal At Best

In the world of federally-funded medical research, the mammoth National Institutes of Health in Bethesda, Md., is sometimes viewed as the "discovery" agency, where scientists study the origins of disease and search for breakthroughs and cures. There's also the much smaller federal Agency for Healthcare Research and Quality, with a budget of about $440 million and a mission to "make health care safer, higher quality, more accessible, equitable and affordable."

PCORI is a third entrant with a different mission, though it can and does also collaborate with other federal agencies. Congress created it in 2010 as an independent institute that specializes in comparative effectiveness research. Under the ACA, the institute receives a mix of Medicare money, general revenue and funding from a tax on health plans.

PCORI is run by a board whose 21 members are picked by the Government Accountability Office, the watchdog arm of Congress, and it has 191 full-time staff. That's up from 153 in September 2014.

Oversight is minimal. A GAO audit in March found little to fault, though auditors noted they had heard concerns that PCORI's research priorities were "too broad and lack specificity." GAO also noted that the institute won't undergo an outside critique of its performance until 2020, after it has run through that $3.5 billion.

No Guarantee That Newer And Costlier Is Better

At least in theory, comparative effectiveness is pretty hard to fault. Common sense dictates that doctors need to know which drugs, medical devices and other treatments work best. And it makes little sense for anyone to pay for health care services that are shown conclusively to be ineffective.

But that's not how things work. New drugs, for instance, come to market based on whether they are "safe and effective," not if they are clearly superior to the competition. While many people might assume that a new medicine or device that costs much more than what's already available must be better, there's no such guarantee. In fact, more than half of medical treatments lack clear evidence of their effectiveness, according to the Institute of Medicine.

Doctors often can't find persuasive evidence to advise them how best to get sick patients well. While many medical groups strongly back research to find these answers, getting their members to embrace recommended changes isn't always easy or quick to happen. Some doctors may be slow to pick up on the most current medical information, while others may resent suddenly being told how they should alter their practice.

Dave deBronkart, a kidney cancer survivor, recalled talking to a doctor who derided "cookbook" medicine. "One doctor told me, 'I want autonomy to practice as I see fit,' " deBronkart said. Like many other advocates, he favors a much greater role for patients in their own care.

Manufacturers of drugs, medical devices and other equipment also have a big stake in comparative research. Some companies have noted a worldwide move to restrict payments for health care services and certain types of drugs that can't clearly demonstrate they are worth the price.

Drafters of the ACA tried to take note of all these competing interests and needs. Despite keen interest in using comparative effectiveness research to cut costs, they yielded to fears that patients could be denied some treatments. As a result, the law appears to restrict use of research findings for cutting costs at the same time that it allows PCORI to consider "the effect on national expenditures associated with a health care treatment" in setting its research priorities.

Testing Whether Nurses Help Reduce Risk Of Falls

Given its mandate, it's perhaps no surprise that PCORI chose many projects that were seemingly worthwhile, but also unlikely to threaten any powerful health care factions.

Since 2012, PCORI has let $389 million in contracts for accelerating its research agenda or "improving healthcare systems."

For instance, the $30 million study anchored by medical schools at Harvard, Yale and UCLA, hopes to reduce falls in the elderly.

Falls "represent grievous events for older persons and a major public health problem," according to the study.

Albert Wu, a health policy professor at Johns Hopkins University who also is involved in the study, said researchers are looking at whether a "specially trained nurse" can work with older people and their relatives to find ways to cut down on these injuries.

"This is a topic that concerns every American who is over 65," said Wu. "We all live in deathly fear an elderly relative will fall and break a hip. It causes terrible worry and distress and a substantial portion of those people die."

Though PCORI director Selby wants little to do with health care financing controversies, the falls study appears to be an exception.

"Putting a nurse in every [doctor's] office doesn't come cheaply," he said. "Who pays for that?" Selby said. Confirming unassailable health benefits of hiring the nurses "would be a big step toward getting coverage for that."

The $14 million aspirin study also has widespread health ramifications because if people take too high a dose they can suffer internal bleeding that may outweigh any heart benefits.

Researchers at Duke University said that every year, 720,000 Americans have a heart attack, and nearly 380,000 die of coronary artery disease. They said that "increasing the use of an inexpensive yet effective therapy, such as aspirin ... will save thousands of lives globally."

"We know that aspirin can be beneficial in preventing heart attacks but surprisingly we haven't known the appropriate dose," said Ann Bonham, chief scientific officer for the Association of American Medical Colleges. "That's an important piece of information...a gap that may not be recognized by a lot of people."

PCORI has also let 18 contracts worth $44 million for research about rare diseases. Among them is $2.6 million awarded to the Cincinnati Children's Hospital Medical Center to study which type of diet to give to children with a condition called eosinophilic esophagitis.

Overall, PCORI can point to $279 million in contracts for the "assessment of prevention, diagnosis and treatment options." Still, that's less than a third of total spending and less than one fifth of the total number of contracts issued thus far.

A Boot Camp To Translate Medical Terms

The Center for Public Integrity review found that tens of millions of dollars in other contracts are for studying research methods, or are looking into how to get findings noticed, or are difficult to decipher.

PCORI has directed $64.5 million toward 66 contracts whose purpose is to improve methods for conducting research. In June 2012, PCORI funded more than $30 million in 50 "pilot projects" mostly at universities and medical schools. One was a boot camp at the University of Colorado Denver for $675,000 over 30 months.

The authors said they would "activate personal relationships to bring together community members, clinical practices, patients, providers and researchers to identify the important health issues they each face." After several meetings, the group would "focus these topics into a priority list for further work." The goal was to translate medical terms to make them easier for patients to grasp.

Some projects toss around esoteric phrases such as "how to capture stakeholder inputs" or "quality metrics to inform integrated care" that aren't likely to be clear to the average reader.

Consider the $674,452 project funded at the Palo Alto Medical Foundation Research Institute with the catchy title: "Creating a Zone of Openness to Increase Patient-Centered Care." The 2012 project explored how medical professionals can foster a climate where patients don't fear being labeled as difficult "for asserting themselves in clinical decision making." PCORI officials said the research produced important insights, though they concede they need to make their work sound more compelling.

Jean R. Slutsky, PCORI's chief engagement and dissemination officer, agreed that heavy use of jargon can be a turnoff, especially for patients the institute is trying to reach.

"We are in the process of putting in lay language to communicate with people who are not scientists," Slutsky said. "We wish we could change this."

The 36 "engagement awards" to health care organizations, universities and groups cost more than $8 million. That includes $500,000 to AHIP, the insurance industry trade group, to "build and maintain support from health plan leaders" and to "identify important gaps in availability of health insurance administrative data," according to summaries of the contracts. AHIP spokeswoman Clare Krusing said sharing health plan data is "complex" and "requires a significant amount of review and expertise from the industry."

PCORI also has provided "meeting and conference support" to medical organizations that totaled more than $1.8 million in 17 grants.

The Society for Academic Emergency Medicine, for instance, received $50,000 in 2015 to develop and publish "a consensus research agenda." The year before, the Society of General Internal Medicine, whose 3,000 physician members teach at medical schools, received a $249,960 grant for a two-year program "to help us develop a better understanding of the attitudes and knowledge of our membership ... and how they may best be engaged to participate."

PCORI director Selby said these awards are necessary to get through to busy professionals who "may not answer our phone calls." Selby said: "Our job is to build relationships and to get on their radar," adding, "This helps us get their attention."

Yes, But What Do Patients Want?

Though it may be largely unknown to the public, PCORI has won support from a wide range of parties.

Former California Congressman Tony Coelho says the data created by PCORI should ultimately be useful for patients when they make health care decisions.

Chip Somodevilla/Getty Images

Tony Coelho, a former Democratic congressman from California who chairs the Partnership to Improve Patient Care, said the institute takes pains to "get first-hand views on what questions really matter to patients."

Coelho's group, a coalition of patient advocates, drug manufacturers and medical groups, applauds PCORI for conducting research "in a manner that is patient-centered and ultimately useful at the point of health care decision making."

Other experts said that putting patients first is itself a worthy research legacy.

PCORI "is filling a really important void," said Justin W. Timbie, a Rand Corporation policy researcher. "This is really practical research to help people make decisions [about their health]. I think that's a lot of bang for the buck."

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. To follow CPI's investigations into Medicare and Medicare Advantage waste, fraud and abuse, go here. Or follow the organization on Twitter: @Publici.

Copyright 2015 The Center for Public Integrity. To see more, visit .
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Could Your Child's Picky Eating Be A Sign Of Depression?

NPR Health Blog - Mon, 08/03/2015 - 5:30pm
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One of the frequent trials of parenthood is dealing with a picky eater. About 20 percent of children ages 2 to 6 have such a narrow idea of what they want to eat that it can make mealtime a battleground.

A study published Monday in the journal Pediatrics shows that, in extreme cases, picky eating can be associated with deeper trouble, such as depression or social anxiety.

The study followed a broad spectrum of children who had come to Duke University for routine medical care. Most kids dislike some foods (broccoli is a common villain), but the researchers counted a child as a severely picky eater if his or her food choices were so limited that it made meals at home difficult, and meals out all but impossible.

Those extreme cases were rare — just 3 percent of all kids. But, as a group, they were twice as likely as the children who weren't picky to have a diagnosis of depression, and seven times as likely to have been diagnosed with social anxiety, according to the study.

Nancy Zucker, director of the Duke Center for Eating Disorders, says parents of children who are extremely finicky may find it useful to seek help, because the kids may not simply outgrow the behavior on their own. And even if they eventually do, it can be disruptive to child and family alike in the meantime.

A big question is what to do about less extreme cases, which in the Duke study made up 17 percent of all children. These children have a list of foods that they are reluctant to stray beyond.

"They're more sensitive to taste, to smell, to texture, to visual clues like light," Zucker says. "They also had higher levels of anxiety symptoms and depressive symptoms." But those symptoms didn't cross the line into a formal diagnosis, she says, "which is important to stress because I really don't want to cause panic among parents."

These children's sensitivities to food mean they "have a potentially richer, more vivid life experience," Zucker says. But "it could be a vulnerability if it crosses a threshold where it starts to impair them."

Finding foods a child will eat is frustrating for many parents, but there's relatively little science on the subject, researchers say. And picky eating isn't just about children — it's about society's broader relationship with food.

"Our notions of what is typical eating have changed radically over the past hundred years," says Kathleen Kara Fitzpatrick, a psychologist at the Stanford University School of Medicine. American children get solid food at an older age, more slowly than they used to, and often with a narrower range of foods.

"That's why most kids' menus in restaurants look exactly the same," Fitzpatrick says.

Discerning eating also has biological roots, she says. "You don't want your kid picking up and eating everything, because then they're going to pick up and eat dirt and hair and cat poop!"

Refusing many foods may, in part, be a natural exaggeration of that natural defense against poisoning. Beverly Tepper, professor of food science at Rutgers University, says these reactions actually occur before food even ends up in a child's mouth.

The first and strongest test is not how food tastes, but what it looks like.

"Once we get past the how-it-looks-stage, and we smell it and it has an attractive odor, we might be interested in consuming it or tasting it," Tepper says.

At that point, texture and taste come into play. Bitterness plays a critical role in accepting or rejecting food (which explains a lot about kids and broccoli). Tepper says an individual's reaction to bitterness is in part a genetic trait, so some children will be naturally more averse to bitter foods.

What's remarkable to her, she says, is not that children often reject bitter foods, but why anyone develops a taste for bitterness.

"Healthier diets tend to be higher in variety," Tepper says. "So this may be a mechanism that ensures greater variety in the diet."

Most of us get more receptive to trying new foods as we grow up — and the process of accepting new foods gets easier. Adults may need to try new foods once or twice before they decide whether they like them or not. In contrast, Fitzpatrick says, typical children may need eight exposures, and "extreme picky eaters can require 52 or more presentations of a food before it's no longer considered novel," she says.

That's one reason it's not easy for parents to train some children out of being too choosy in what they eat. It can take a lot of work, but may be worth it in some cases.

"What I suggest parents do is, if there are going to be 'food adventures,' that they happen during snack," Zucker says.

It's best not to disrupt the socially important time around meals to do battle over food, she says.

And remember, most children eventually will develop a much broader palate.

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Snail Venom Yields Potent Painkiller, But Delivering The Drug Is Tricky

NPR Health Blog - Mon, 08/03/2015 - 3:30pm
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The sea snail Conus magus looks harmless enough, but it packs a venomous punch that lets it paralyze and eat fish. A peptide modeled on the venom is a powerful painkiller, though sneaking it past the blood-brain barrier has proved hard.

Courtesy of Jeanette Johnson and Scott Johnson

Researchers are increasingly turning to nature for inspiration for new drugs. One example is Prialt. It's an incredibly powerful painkiller that people sometimes use when morphine no longer works. Prialt is based on a component in the venom of a marine snail.

Prialt hasn't become a widely used drug because it's hard to administer. Mandë Holford is hoping to change that. She and colleagues explain how in their study published online Monday in the journal Scientific Reports.

Shots - Health News How A Scientist's Slick Discovery Helped Save Preemies' Lives

Holford is an associate professor of chemical biology at Hunter College in New York and on the scientific staff of the American Museum of Natural History. As is so often the case in science, her path to working on Prialt wasn't exactly a direct one. She's a chemist, and her first passion was peptides — short strings of amino acids that do things inside cells.

"I started out with this love for peptides," Holford says, then laughs. "Love! Sounds weird to say you love peptides out loud."

When Holford was in graduate school, a visiting scientist named Toto Olivera gave a lecture about the peptides in snail venom.

"He has this amazing video of a snail eating a fish," she says, "and it just looked so crazy." National Geographic has a similar video posted on YouTube.


Holford was captivated. How could a snail eat a fish? The secret, she learned, was a powerful venom the snail uses to paralyze the fish.

"It's amazing," Holford says.

Now, it turns out this venom is made of a hundred or more different peptides, most of them harmful to people.

"If I were to inject you with the complete cocktail of cone snail venom, it would kill you," says Holford. But one particular peptide in the venom is able to do something medically useful: It dramatically reduces pain. In 2004, the FDA approved the drug Prialt, made from a synthetic form of this particular peptide. Right now, Prialt is only used in cases of extreme, unrelenting pain because there's a major problem with the drug.

"It doesn't cross the blood-brain barrier," Holford explains.

The blood-brain barrier is a kind of membrane that prevents most compounds in the blood from entering the brain. In many ways, that layer of protection is helpful, but if Prialt doesn't get into the brain, it can't ease pain.

So, at this point, the drug can only be administered via an injection directly into the spinal column — which isn't very convenient for patient or doctor.

Holford has been looking for an easier way in. "We're using what I call our 'Trojan horse strategy,' in which we put the peptide inside of a carrier — which is called, in this case, a viral nanocontainer," she says. It's a tiny receptacle made from proteins found in viruses.

"Then," Holford explains, "we sort of shuttle it across the blood-brain barrier, using another peptide, which is a cell-penetrating peptide, which can cut through all sorts of membranes — including the blood-brain barrier."

As Holford and her Hunter College colleague Prachi Anand note in their journal report, the system seems to work in a laboratory model of the brain barrier. If her idea stands up to further testing, it would be possible to inject the drug intravenously — or maybe someday just take it as a pill.

But there's still a lot to do before Holford and her colleagues will know if that's really possible.

"The next step is to figure out if the peptide is still functional once we get it across the blood-brain barrier," says Holford. In other words, whether it still works as a painkiller once it's delivered with Holford's Trojan horse.

I'll report back when they've figured that out.

This story is part of Joe Palca's series Joe's Big Idea, an exploration of how ideas become innovations and inventions.

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Calls To Cut Off Planned Parenthood Are Nothing New

NPR Health Blog - Mon, 08/03/2015 - 1:22pm

Protesters rally on the steps of the Texas state capitol on July 28 to condemn the use of fetal tissue for medical research.

Eric Gay/AP

Updated at 6:52 p.m. ET

Republican calls to defund Planned Parenthood over its alleged handling of fetal tissue for research are louder than ever. But they are just the latest in a decades-long drive to halt federal support for the group.

This round aims squarely at the collection of fetal tissue, an issue that had been mostly settled — with broad bipartisan support — in the early 1990s. Among those who voted then to allow federal funding for fetal tissue research was now-Senate Majority Leader Mitch McConnell, R-Ky.

McConnell made no mention of his previous position when he announced that the Senate would take up a bill to cut off Planned Parenthood's access to federal funds before leaving for its summer break. The Senate blocked the legislation from moving forward Monday night, but the issue may come back with spending bills in the fall.

Videos shot by members of an anti-abortion group posing as fetal tissue middlemen "absolutely shock the conscience," McConnell said at a news conference last week. Those videos purport to show Planned Parenthood officials discussing the sale of tissue from aborted fetuses in strikingly casual terms. It is illegal to profit from the sale of fetal tissue, though not illegal for expenses involved in its collection to be reimbursed.

Senate Majority Leader Mitch McConnell, R-Ky., has voted in support of fetal tissue research in the past.

Susan Walsh/AP

Planned Parenthood says the videos are heavily edited and take discussions out of context.

"These videos are hard for anyone to defend and hit at the moral fabric of our society," said the bill's lead sponsor, Sen. Joni Ernst, R-Iowa. "Planned Parenthood is harvesting the body parts of unborn babies."

Ernst's bill would have not only made Planned Parenthood ineligible for federal grant programs like the federal family planning program, but also would have banned it from receiving reimbursement from Medicaid for other health services it performs for eligible men and women, such as testing and treatment for sexually transmitted diseases.

According to the group's most recent annual report, 41 percent of the $1.3 billion received by the national group and its affiliates came from government sources. Under a series of laws including the Hyde amendment, none of the federal funds can be used for abortions, which account for 3 percent of the services Planned Parenthood provides.

Yet even though abortion is a small part of what Planned Parenthood does, the group's enormous size makes it the nation's largest single provider of the procedure.

The debate is in fact all about abortion, according to Dawn Laguens, executive vice president of Planned Parenthood. "They don't care about fetal tissue research," she says of the groups targeting the organization. "It is just an angle to go after safe, legal abortion."

Asked if the goal was to eliminate funding for Planned Parenthood, fetal tissue research or both, David Daleiden, the head of the Center for Medical Progress, the group that took the videos, said in a statement: "The goal of our investigation is to reveal the truth about Planned Parenthood's trafficking and sale of aborted baby body parts for profit, which is illegal and unethical. Taxpayers should not be paying for these atrocities against humanity."

But while the tie to fetal tissue is new, the fight to separate Planned Parenthood from its federal funding is, in fact, older than the 26-year-old Daleiden.

In 1982, when Ronald Reagan was president, his administration issued the so-called squeal rule, which sought to require family planning providers, including Planned Parenthood, to notify parents when providing contraceptives to minors or lose their funding. Planned Parenthood sued and won in federal court, where the rule was found to be a violation of patient privacy.

In 1987, the Reagan administration issued what came to be known as the "gag rule," which barred recipients of federal family planning funds from counseling or referring patients for abortion, and which required physical and financial separation between contraceptive and abortion services.

Planned Parenthood and others sued again, and the case eventually went to the Supreme Court. This time the government won, but the rules remained mired in lower courts and were never fully implemented. President Bill Clinton erased them on his first day in office in 1993 by executive order.

Planned Parenthood was back on the hot seat in the 2000s, as new "direct action" groups decided to take the fight in a different direction.

In 2011, the anti-abortion group Live Action released a series of videos charging that Planned Parenthood was failing to act in apparent cases of sexual abuse leading to abortion in minors. Republicans in the House helped use those videos (which were later found to have been edited to make them misleading) to pass an amendment to defund Planned Parenthood. The Democratic-led Senate never acted on the measure.

But even those inclined to support Planned Parenthood say the allegations around the sale of fetal tissue may represent a turning point.

"The imagery is terrible," said Alta Charo, a professor of law and bioethics at the University of Wisconsin.

This is also ironic, she says, because there has been a fairly broad bipartisan consensus in favor of using tissue from aborted fetuses in research for many years.

A panel appointed during the Reagan administration in 1988 voted overwhelmingly that such research was ethical.

"They went through all of the arguments, like 'Does it make you complicit and evil if you take advantage of what had been a legally aborted fetus and you think that abortion was evil?' And the answer was, 'Well no, because we have transplants of organs of homicide victims all the time,' " Charo said. "So even if you call it a homicide, we take advantage of it."

Meanwhile, groups looking for possible cures for devastating diseases, and seeing potential breakthroughs in other countries, urged Congress to cancel a federal funding ban on fetal tissue research imposed by Reagan and continued under President George H.W. Bush.

That support was demonstrated in a bill to update programs at the National Institutes of Health. Among the Republicans who joined the overwhelming support for the measure in 1992 were not only McConnell, but also Sens. Charles Grassley, R-Iowa, and John McCain, R-Ariz.

Bush vetoed that bill, as promised, and while the Senate voted almost as overwhelmingly to override the veto, the House fell 10 votes short of the two-thirds majority needed.

President Bill Clinton overturned the ban by executive order in 1993, and federal funding for fetal tissue research was formally authorized in a similar NIH bill passed later that year.

Copyright 2015 Kaiser Health News. To see more, visit
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How A Scientist's Slick Discovery Helped Save Preemies' Lives

NPR Health Blog - Mon, 08/03/2015 - 4:57am
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Researcher John Clements in the early 1980s, after he figured out that lungs need surfactants to breathe.

David Powers/Courtesy of UCSF

In 1953, Dr. John Clements realized something fundamental about the way the lung functions — an insight that would ultimately save the lives of millions of premature babies.

The story begins in 1950, when the U.S. Army sent Clements, a newly graduated physician, to the medical division of what was then called the Army Chemical Center in Edgewood, Md. Clements was interested in doing research in biochemistry. His commanding officer was of a different mind.

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" 'We don't need any biochemists,' " Clements recalls the officer saying. " 'You're going to be a physiologist.' And I became a physiologist because the Army said so."

At the time, the Army was worried about the Soviet Union using chemical weapons.

"My assignment was to find out how nerve gases worked on the lungs," says Clements. So he set out to learn all he could about human lungs.

Lungs are made up of thin, pliable sacs called alveoli. You can think of them as tiny, somewhat permeable balloons. Oxygen enters the bloodstream through the outer membranes of these sacs.

When the sacs inflate, there's more surface area for oxygen to cross into the blood.

The tiny sacs in the lungs, called alveoli, move oxygen into the blood and carbon dioxide out.

Eye of Science/Science Source

But how much surface area is there in the normal lung? This wasn't an easy question to answer. Researchers who had looked at lung tissue through the microscope said the surface area was huge — maybe the size of a football field if you spread it all out.

But physiologists who estimated the energy that's used to inflate the sacs came up with a much, much smaller area.

"That huge discrepancy between two supposedly correct methods bothered me," Clements says.

In 1953, he suggested an explanation for the discrepancy. Maybe there was a substance in the lung that made the alveoli easier to inflate and keep inflated. A few years later, Clements and others found it — a slippery substance known as a surfactant that reduces surface tension in the alveolar membranes. Soon scientists showed that a lack of surfactant is involved in human lung disease.

"At that point the research, to use the trite term, exploded," Clements says.

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Clements was doing basic research, not trying to cure a disease. But his work did contribute to a cure. In 1959, a researcher named Dr. Mary Ellen Avery, who was then at Harvard Medical School, showed that the lungs of premature babies can't make that surfactant. In those days, many children born at less than 37 weeks' gestation would die from something called respiratory distress syndrome, or RDS.

The FDA has since approved five synthetic surfactants to prevent respiratory distress syndrome in premature babies. Surfaxin, approved in 2012, is the latest to hit the market. (The first, Exosurf, is no longer sold.)

"It took 40 years — from the initial discovery in the early '50s to the first approval of the FDA in the 1990s," says Dr. Sam Hawgood, a neonatologist who once worked in Clements' lab and is now chancellor at the University of California, San Francisco.

"All of us would like to compress that timeline," Hawgood says. "But if you think that we had no idea that this substance even existed or was needed in the '50s, to an actual drug four decades later — it's pretty remarkable."

What's also remarkable is John Clements himself. Today he has a lab at UCSF. At 92, he still heads in every day and is proud of what his work has meant for treating premature infants with respiratory distress syndrome.

"When we began this work back in the 1950s, the mortality from RDS was above 90 percent," he says. "Today, that mortality is 5 percent or less."

I asked Clements why he still works — surely he's achieved enough to rest on his laurels. He says there's always the chance that a new day will bring a new scientific insight.

"The thrill of that is the best thing there is. At my age, I'd put it even higher than sex," says Clements with a laugh. Then his tone is more serious. "It's a big, big thrill when you think you've made a discovery — found an idea — that no one else has had," he says. "That's as good as it gets."

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No Shame, No Euphemism: Suicide Isn't A Natural Cause Of Death

NPR Health Blog - Sat, 08/01/2015 - 7:03am
Keith Negley for NPR

Beware the mention of natural causes, as in my mother's obituary:

"Norita Wyse Berman, a writer, stockbroker and artist ... died at home Friday of natural causes. She was 60."

Sixty-year-olds don't die of natural causes anymore. The truth was too hard to admit.

Fifteen years on, I'm ashamed of my family's shame. Those attending her funeral and paying shiva calls knew the truth anyway. People talk.

One of the many ironies of dying young is that my mother was a true believer in modern medicine. She had a cabinet full of elixirs and potions for which she paid top dollar. For most of her life she never paid retail for anything, so the medicine cabinet was testament to her insecurity about fleeting beauty and a quest for longevity. Others around her might succumb to aging, but my mom had confidence that her vitamins and nutraceuticals could hold back Father Time.

Her anxieties predated the Internet and the rise of Dr. Oz. I know she'd have become a big fan of the telegenic surgeon, and would have asked why I couldn't have a practice more like his. After all, she told me more than once, "Making money is not a sin."

She divorced my father when I was 12. She wanted a career, which was an idea my father did not support. Eventually she became a stockbroker, and in spite of limited financial acumen, she became very successful. She had natural sales ability and made brilliant use of her greatest talent — networking. The fact that the 1980s and '90s witnessed two of the greatest bull markets in Wall Street history certainly helped.

The Schumann family in 1972, including the author, age 3 1/2, center.

Courtesy of John Henning Schumann

My mother remarried soon after my parents' divorce. But 15 years into her career, my stepfather convinced her to retire because of his own declining health.

They moved to Florida, accelerating their senescence by living in a gated golf community. Finances were no issue, but my mother's mental state soon started to unravel.

My mother hated golf. She tried other pursuits like painting and travel. But retirement simply wasn't for her. My sense was she'd lost her self-worth when she no longer felt like a stock market titan.

One day my stepfather called to let me know that he found my mother lying on the floor of the garage with the car running. It was time to get help.

Thus began my family's odyssey in the mental health care system.

Over the next five years, my mother would bounce between despondent lows and powerful highs. Diagnoses abounded, depending on where in the cycle she was. One doctor labeled her bipolar, another "majorly depressed with psychotic features."

Medicines were started, adjusted and then new ones were added. Her doctors tried mightily to find the right cocktail of drugs so she could stay in balance.

Eventually most of her improvement came from lithium. But she hated taking it because it made her urinate frequently and because she saw it as a relic. If she had to be on medication, why couldn't it be one of these newer-fangled drugs with a more impressive name and less stigma?

My mom was the type of patient who thinks there's a pill for every ailment. Antibiotics for colds. Weight-loss pills. Sleep aids. The silver-bullet theory of medicine. She even underwent shock therapy as a potential quick fix. But because her psych meds earned her the label "crazy," she sought any opportunity to shed them.

Twice this behavior led her to other suicide attempts. Her doctors called them gestures. We wanted to believe that she didn't have real intent.

My mother's behavior taught me the first practical thing I learned in medical school: Don't stop taking medication for a chronic condition without first telling someone. Like hospitalized patients that "cheek" their pills, my Mom lied to her doctors about taking her medications because she didn't want to be nagged and didn't want to be dependent on them.

But without her pills her mental health was far too fragile.

We were stuck in twin binds. My mother loved medicines and their potential for miracles, but she always sought to ditch them the moment she felt better.

As my mother's mental health struggles surfaced, I was on my way to becoming a doctor. But I was powerless to help someone closest to me.

It's not that my mother didn't believe in my healing powers. On my very first day of med school I called home to debrief. "I have a rash I need you to take a look at," she interjected.

Did she really think after Day 1 I knew anything about doctoring?

Looking back, I can now see that my mom was giving me my earliest lesson in the culture of expectations. There's a reason medical ethicists warn against treating family and friends. Corners get cut. Judgment becomes impaired. Honesty becomes scarce.

Throughout her illness I believed that I was there for my mother. In our talks I was able to cut through the bull she fed everyone else. My intention was to let her know that my newly acquired medical knowledge would always be available to her. I wanted her to trust me.

But the more I pressed, the farther she receded. She put up a brave front, so convincing that she bluffed her way past my fledgling diagnostic skills. In her last rise out of the depths, we all hoped against reality that she was on the road to a permanent recovery.

Then she hung herself on the day after Thanksgiving.

It's painful to admit even now. But I no longer feel shame. Sadness, yes. Even anger still, though that ebbs.

I also harbor the hope that others can learn from her illness and death. If suicide remains in the shadows of stigma and superstition, it will always plague us.

Suicide, after all, is not a natural cause of death.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as interim president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa's Medical Matters. He's on Twitter: @GlassHospital

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